A7: How Safety 2 thinking helps improve haemovigilance, diagnostic error and allows us to learn from excellence

Tuesday 21 June 2022 | 11:00-12:30

Format: Presentation
Stream: Safety
Content filters: Features discussion of improvement methodology, Co-presented with patients, service users or carers

(Part A) Taking healthcare safety to the next level using lessons from haemovigilance

Patient safety incidents impact patients, family, friends, and carers have an emotional and professional impact on staff involved, a cultural impact on the department and reputational damage to the organisation. Serial data from Serious Hazards of Transfusion (SHOT), the UK haemovigilance scheme shows that while transfusions are safe, errors continue.

Now is the time to reevaluate the way we look at patient safety and incident investigations. This session will give delegates the knowledge and tools to incorporate human factors and systems thinking principles into their own working environment and use a combined Safety-I and Safety-II approach to improve patient safety.

Shruthi Narayan, Serious Hazards of Transfusion; England

Charlotte Silver, NHS Blood and Transplant; England

(Part B) Moving from diagnostic error to diagnostic safety

We’ve changed the focus from diagnostic error to diagnostic safety. From safety 1 to safety 2. Our aim is to make the patient and relatives safe in their contact with health care but also make the system safer for the clinicians. The patient and relatives are encouraged to be active in the diagnosis process.

We have used adverse event reporting and complaints to initiate our improvement work. We have also tried to calculate the extra cost for the health care system when a diagnosis is delayed, not given or wrong.

Pär Lindgren, Region Kronoberg; Sweden

Linda Hördegård, Region Kronoberg; Sweden

(Part C) Practice what you preach: experiences with ’learning from excellence’ in a tertiary pediatric centre

There is increasing evidence from Safety 2 research that vigorously analyzing the positive outliers in patient care, can improve patient safety even more. As a resident in Pediatrics and trainer in a foundation called ‘Leading Doctors’, founded to stimulate professional fulfillment, we developed a program in our hospital (a tertiary children’s hospital) to detect and evaluate excellent cases. Our project was inspired by Adrian Plunkett and his model for Learning from Excellence.

This session will give delegates an overview of how we build this project and what our results are, as well as practical tools to incorporate ‘Learning from excellence’ in their own working environment.

Marije Smits, Resident in Pediatrics; Netherlands